Life Company Enrollment Form

Employer Name/Company Name: County: Employer ZIP: State:

Employee Last Name: First Name: Middle Initial: Social Security Number: Date of Birth:

Spouse Last Name: First Name: Middle Initial: Social Security Number: Date of Birth:

Street Address: City: State: Zip:

Gender: Male Female Marital Status: Married Single Home Phone Work Phone

Completed By Employer

Average Hours Worked Per Week: Occupation:

Earnings: Hourly Monthly Weekly Yearly $

Date of Full-Time Employment: Rehire Date:

Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.

All coverage amounts are subject to the limitations and exclusions as stated in the policy.

Basic Group Life/AD&D Yes No* Class: Effective Date: $ $

Dependent Life Yes No* Class: Effective Date: $ $

Optional Employee Life/AD&D Yes No* $ $

Optional Spouse Life/AD&D Yes No* $ $

Optional Child Life Yes No* $ $

Short Term Disability Yes No* $ $

Long Term Disability Yes No* $ $

Dental Yes No Employee Only Employee/Spouse Employee/Children Employee/Spouse/Children $

NOTE: Please mark the box or boxes for each coverage you are applying for.

All coverage amounts are subject to the limitations and exclusions as stated in the policy.

Has Employee or Spouse used any type of tobacco or nicotine in the past 12 months? Employee: Yes No Spouse: Yes No

TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM

Voluntary Employee Life Insurance Yes No* $ $

Voluntary Employee Optional AD&D Yes No* Equal to Life Insurance Amount $

Voluntary Spouse Life Insurance Yes No* $ $

Voluntary Spouse Optional AD&D Yes No* Equal to Life Insurance Amount $

Voluntary Dependent Child Benefit Yes No* $

Voluntary Short Term Disability Yes No* Weekly Benefit Amount $ $

Voluntary Long Term Disability Yes No* Monthly Benefit Amount $ $

Voluntary Dental Yes No Employee Only Employee/Spouse Employee/Children Employee/Spouse/Children $

Voluntary Vision Yes No Employee Only Employee/Spouse Employee/Children Employee/Spouse/Children $

Voluntary Accidental Death & Dismemberment (Standalone) Yes No Employee Only Employee and Family $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $

NOTE: Please mark the box or boxes for each plan/benefits you are applying for.

All coverage amounts are subject to the limitations and exclusions as stated in the policy.

Accident Yes No If Yes, Select One: Select Choice Preferred Elite

Employee Only Employee Plus Spouse Employee Plus Child(ren) Family $

The following Optional Benefits may be elected if Accident coverage is elected.

Accident coverage for Dependents must be elected in order to elect any Dependent coverage for the Optional Benefits.

Health Assessment - $50 Yes No Employee Only Employee Plus Spouse Employee Plus Child(ren) Family $

Sickness Hospital Confinement - $100 Yes No Employee Only Employee Plus Spouse Employee Plus Child(ren) Family $

Accident Sickness Disability - $2,000 Yes No Employee Only Employee Plus Spouse $

Accident Disability - $2,000 Yes No Employee Only Employee Plus Spouse $

NOTE: Please mark the box or boxes for each plan/benefits you are applying for.

All coverage amounts are subject to the limitations and exclusions as stated in the policy.

Employee or Spouse tobacco/nicotine use in past 12 months: Employee Yes No Spouse Yes No

Type of Coverage Plan Option(s) Amount of Coverage Weekly Premium

Critical Illness Yes No* Base Plan includes:
Wellness Category
Heart Category
Cancer Category
Organ Category
Quality of Life Category
Child Category**
Treatment Care Benefit***
Permanent and Total Disability Benefit
Accident Benefit
Occupational HIV/Occupational Hepatitis Benefit**** Employee
Spouse*
Child** $15,000
$25,000
$50,000
$10,000
$20,000
$50,000
$10,000
$25,000 $

$

$

The following Optional Benefit(s) may be elected if Critical Illness coverage is elected.

Optional Plan Options will equal the amount of the Base Plan(s) checked above. Critical Illness coverage for Dependents must be elected in order to elect any Dependent coverage for the optional benefit.

Optional Benefit Plan Option(s) Amount of Coverage Weekly Premium

Heart Category Yes No* Employee

Spouse

Child $15,000
$25,000
$50,000
$10,000
$20,000
$50,000
$10,000
$25,000 $

$

$

Cancer Category Yes No* Employee

Spouse

Child $15,000
$25,000
$50,000
$10,000
$20,000
$50,000
$10,000
$25,000 $

$

$

Primary Beneficiary's Last Name: First: MI: Relationship of Beneficiary: Social Security Number:

Street Address: City: State: Zip:

Contingent Beneficiary's Last Name: First: MI: Relationship of Beneficiary: Social Security Number:

Street Address: City: State: Zip:

Last Name First Name Middle Initial Gender Date of Birth Full-time Student

Child 1 Last Name: First Name: Middle Initial: Gender: Date of Birth: Yes No

Child 2 Last Name: First Name: Middle Initial: Gender: Date of Birth: Yes No

Child 3 Last Name: First Name: Middle Initial: Gender: Date of Birth: Yes No

Child 4 Last Name: First Name: Middle Initial: Gender: Date of Birth: Yes No

Are you or any of your eligible dependents covered by any other dental/vision plan? YES (If YES, please list) NO

Name of Insured Insurance Company Name/Phone and Policy Number Employer Coverage

Dental Vision

Dental Vision

Dental Vision

This coverage has been offered to me and after careful consideration of the benefits, I have decided to:

REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary.

NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

NOT ENROLL my dependents in the Program. I understand that if I enroll for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

NOTE: A PERSON MAY BE COMMITTING INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY.

The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect.

I understand that the vision care insurance benefit plan I have selected provides reimbursement for certain vision costs which are more fully described in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my provider or me for vision care expenses which I have incurred may not be covered by my vision care insurance benefit plan.